AMERICAN THORACIC SOCIETY DOCUMENTS - GDPharmD
嚜澤MERICAN THORACIC SOCIETY
DOCUMENTS
Diagnosis and Treatment of Adults with Community-acquired
Pneumonia
An Of?cial Clinical Practice Guideline of the American Thoracic Society and
Infectious Diseases Society of America
Joshua P. Metlay*, Grant W. Waterer*, Ann C. Long, Antonio Anzueto, Jan Brozek, Kristina Crothers, Laura A. Cooley,
Nathan C. Dean, Michael J. Fine, Scott A. Flanders, Marie R. Grif?n, Mark L. Metersky, Daniel M. Musher,
Marcos I. Restrepo, and Cynthia G. Whitney; on behalf of the American Thoracic Society and Infectious Diseases
Society of America
THIS OFFICIAL CLINICAL PRACTICE GUIDELINE WAS APPROVED BY THE AMERICAN THORACIC SOCIETY MAY 2019 AND THE INFECTIOUS DISEASES SOCIETY OF AMERICA
AUGUST 2019
Background: This document provides evidence-based clinical
practice guidelines on the management of adult patients with
community-acquired pneumonia.
Methods: A multidisciplinary panel conducted pragmatic
systematic reviews of the relevant research and applied Grading of
Recommendations, Assessment, Development, and Evaluation
methodology for clinical recommendations.
Results: The panel addressed 16 speci?c areas for recommendations
spanning questions of diagnostic testing, determination of site of
care, selection of initial empiric antibiotic therapy, and subsequent
Contents
Overview
Introduction
Methods
Recommendations
management decisions. Although some recommendations remain
unchanged from the 2007 guideline, the availability of results from
new therapeutic trials and epidemiological investigations led to
revised recommendations for empiric treatment strategies and
additional management decisions.
Conclusions: The panel formulated and provided the rationale for
recommendations on selected diagnostic and treatment strategies
for adult patients with community-acquired pneumonia.
Keywords: community-acquired pneumonia; pneumonia; patient
management
Question 1: In Adults with CAP,
Should Gram Stain and Culture
of Lower Respiratory Secretions
Be Obtained at the Time of
Diagnosis?
Question 2: In Adults with CAP,
Should Blood Cultures Be
Obtained at the Time of Diagnosis?
Question 3: In Adults with CAP,
Should Legionella and
*Co每first authors.
Endorsed by the Society of Infectious Disease Pharmacists July 2019.
ORCID IDs: 0000-0003-2259-6282 (J.P.M.); 0000-0002-7222-8018 (G.W.W.); 0000-0002-7007-588X (A.A.); 0000-0002-3122-0773 (J.B.);
0000-0001-9702-0371 (K.C.); 0000-0002-5127-3442 (L.A.C.); 0000-0002-1996-0533 (N.C.D.); 0000-0003-3470-9846 (M.J.F.);
0000-0002-8634-4909 (S.A.F.); 0000-0001-7114-7614 (M.R.G.); 0000-0003-1968-1400 (M.L.M.); 0000-0002-7571-066X (D.M.M.);
0000-0001-9107-3405 (M.I.R.); 0000-0002-1056-3216 (C.G.W.).
Supported by the American Thoracic Society and Infectious Diseases Society of America.
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the U.S. CDC.
An Executive Summary of this document is available at .
You may print one copy of this document at no charge. However, if you require more than one copy, you must place a reprint order. Domestic reprint orders:
amy.schriver@; international reprint orders: louisa.mott@.
This article has an online supplement, which is accessible from this issue*s table of contents at .
Am J Respir Crit Care Med Vol 200, Iss 7, pp e45每e67, Oct 1, 2019
Copyright ? 2019 by the American Thoracic Society
DOI: 10.1164/rccm.201908-1581ST
Internet address:
American Thoracic Society Documents
e45
AMERICAN THORACIC SOCIETY DOCUMENTS
Pneumococcal Urinary Antigen
Testing Be Performed at the
Time of Diagnosis?
Question 4: In Adults with CAP,
Should a Respiratory Sample Be
Tested for In?uenza Virus at the
Time of Diagnosis?
Question 5: In Adults with CAP,
Should Serum Procalcitonin plus
Clinical Judgment versus
Clinical Judgment Alone Be
Used to Withhold Initiation of
Antibiotic Treatment?
Question 6: Should a Clinical
Prediction Rule for Prognosis
plus Clinical Judgment versus
Clinical Judgment Alone Be
Used to Determine Inpatient
versus Outpatient Treatment
Location for Adults with CAP?
Question 7: Should a Clinical
Prediction Rule for Prognosis
plus Clinical Judgment versus
Clinical Judgment Alone Be
Used to Determine Inpatient
General Medical versus Higher
Overview
In the more than 10 years since the last
American Thoracic Society(ATS)/Infectious
Diseases Society of America (IDSA)
community-acquired pneumonia (CAP)
guideline (1), there have been changes in
the process for guideline development, as
well as generation of new clinical data. ATS
and IDSA agreed on moving from the
narrative style of previous documents to the
Grading of Recommendations Assessment,
Development, and Evaluation (GRADE)
format. We thus developed this updated
CAP guideline as a series of questions
answered from available evidence in an ※is
option A better than option B§ format
using the Patient or Population,
Intervention, Comparison, Outcome
(PICO) framework (2).
Given the expansion in information
related to the diagnostic, therapeutic, and
management decisions for the care of
patients with CAP, we have purposely
narrowed the scope of this guideline to
address decisions from the time of clinical
diagnosis of pneumonia (i.e., signs and
symptoms of pneumonia with radiographic
con?rmation) to completion of
antimicrobial therapy and follow-up chest
e46
Levels of Inpatient Treatment
Intensity (ICU, Step-Down, or
Telemetry Unit) for Adults with
CAP?
Question 8: In the Outpatient
Setting, Which Antibiotics Are
Recommended for Empiric
Treatment of CAP in Adults?
Question 9: In the Inpatient
Setting, Which Antibiotic
Regimens Are Recommended
for Empiric Treatment of
CAP in Adults without Risk
Factors for MRSA and
P. aeruginosa?
Question 10: In the Inpatient
Setting, Should Patients
with Suspected Aspiration
Pneumonia Receive Additional
Anaerobic Coverage beyond
Standard Empiric Treatment for
CAP?
Question 11: In the Inpatient
Setting, Should Adults with CAP
and Risk Factors for MRSA or
P. aeruginosa Be Treated with
imaging. The document does not address
either the initial clinical diagnostic criteria
or prevention of pneumonia.
CAP is an extraordinarily
heterogeneous illness, both in the range
of responsible pathogens and the host
response. Thus, the PICO questions we
identi?ed for this guideline do not represent
the full range of relevant questions about the
management of CAP but encompass a set of
core questions identi?ed as high priority by
the panel. In addition, although each
question was addressed using systematic
reviews of available high-quality studies,
the evidence base was often insuf?cient,
emphasizing the continued importance of
clinical judgment and experience in treating
patients with this illness and the need for
continued research.
Introduction
This guideline addresses the clinical entity of
pneumonia that is acquired outside of the
hospital setting. Although we recognize that
CAP is frequently diagnosed without the use
of a chest radiograph, especially in the
ambulatory setting, we have focused on
studies that used radiographic criteria for
Extended-Spectrum Antibiotic
Therapy Instead of Standard
CAP Regimens?
Question 12: In the Inpatient
Setting, Should Adults
with CAP Be Treated with
Corticosteroids?
Question 13: In Adults with CAP
Who Test Positive for In?uenza,
Should the Treatment Regimen
Include Antiviral Therapy?
Question 14: In Adults with
CAP Who Test Positive for
In?uenza, Should the Treatment
Regimen Include Antibacterial
Therapy?
Question 15: In Outpatient and
Inpatient Adults with CAP Who
Are Improving, What Is the
Appropriate Duration of
Antibiotic Treatment?
Question 16: In Adults with CAP
Who Are Improving, Should
Follow-up Chest Imaging Be
Obtained?
Conclusions
de?ning CAP, given the known inaccuracy
of clinical signs and symptoms alone for
CAP diagnosis (3). This guideline focuses
on patients in the United States who have
not recently completed foreign travel,
especially to regions with emerging
respiratory pathogens. This guideline also
focuses on adults who do not have an
immunocompromising condition, such as
inherited or acquired immune de?ciency or
drug-induced neutropenia, including
patients actively receiving cancer
chemotherapy, patients infected with HIV
with suppressed CD4 counts, and solid
organ or bone marrow transplant
recipients.
Antibiotic recommendations for the
empiric treatment of CAP are based on
selecting agents effective against the major
treatable bacterial causes of CAP.
Traditionally, these bacterial pathogens
include Streptococcus pneumoniae,
Haemophilus in?uenzae, Mycoplasma
pneumoniae, Staphylococcus aureus,
Legionella species, Chlamydia pneumoniae,
and Moraxella catarrhalis. The microbial
etiology of CAP is changing, particularly
with the widespread introduction of the
pneumococcal conjugate vaccine, and there
is increased recognition of the role of viral
American Journal of Respiratory and Critical Care Medicine Volume 200 Number 7 | October 1 2019
AMERICAN THORACIC SOCIETY DOCUMENTS
pathogens. The online supplement contains
a more detailed discussion of CAP
microbiology. As bacterial pathogens often
coexist with viruses and there is no current
diagnostic test accurate enough or fast
enough to determine that CAP is due solely
to a virus at the time of presentation (see
below), our recommendations are to
initially treat empirically for possible
bacterial infection or coinfection. In
addition, the emergence of multidrugresistant pathogens, including methicillinresistant S. aureus (MRSA) and
Pseudomonas aeruginosa, requires separate
recommendations when the risk of
each of these pathogens is elevated. We
acknowledge that other multidrug-resistant
Enterobacteriaceae can cause CAP,
including organisms producing extendedspectrum b-lactamase, but we do not
discuss them separately because they are
much less common and are effectively
covered by the strategies presented for
P. aeruginosa. Therefore, throughout this
document when discussing P. aeruginosa
we are also referring to other similar
multiresistant gram-negative bacteria.
We have maintained the convention
of separate recommendations on the
basis of the severity of illness. Although
historically site of care (outpatient,
inpatient general ward, or ICU) has served
as a severity surrogate, decisions about site
of care may be based on considerations
other than severity and can vary widely
between hospitals and practice sites.
We have therefore chosen to use the
IDSA/ATS CAP severity criteria that have
been validated and de?ne severe CAP as
present in patients with either one major
criterion or three or more minor criteria.
(Table 1)
This guideline reaf?rms many
recommendations from the 2007 statement.
However, new evidence and a new process
have led to signi?cant changes, which are
summarized in Table 2.
Methods
The guideline development methodology
and how con?ict of interest was managed
are presented in the online supplement. In
brief, the list of PICO questions was ?nalized
based on a prioritization of the most
important management decisions balanced
against the decision to reduce the overall
length of the document and total number of
American Thoracic Society Documents
recommendations to maximize readability
and usability. We followed the GRADE
standards for evaluating the evidence for
each PICO and assigned a quality of
evidence rating of high, moderate, low, or
very low. On the basis of the quality of
evidence, recommendations were assigned
as strong or conditional. In some cases,
strong recommendations were made in the
setting of low or very low quality of evidence
in accordance with the GRADE rules for
when such recommendations are allowable
(e.g., when the consequences of the
recommendation were high, such as
preventing harm or saving life). In all other
cases, recommendations that were based on
low or very low quality of evidence and not
believed to represent standards of care were
labeled as conditional recommendations.
Statements in favor of strong
recommendations begin with the words
※We recommend . . .§; statements in favor
of conditional recommendations begin
with the words ※We suggest . . . .§
Although we speci?ed pairwise PICO
questions for all antibiotic options in the
outpatient and inpatient settings, we
summarized the recommendations using
lists of treatment options, in no preferred
order, rather than retain the PICO format
for this section.
Recommendations
Question 1: In Adults with CAP,
Should Gram Stain and Culture of
Lower Respiratory Secretions Be
Obtained at the Time of Diagnosis?
Recommendation. We recommend not
obtaining sputum Gram stain and culture
routinely in adults with CAP managed in the
outpatient setting (strong recommendation,
very low quality of evidence).
We recommend obtaining pretreatment
Gram stain and culture of respiratory
secretions in adults with CAP managed in
the hospital setting who:
1. are classi?ed as severe CAP (see Table 1),
especially if they are intubated (strong
recommendation, very low quality of
evidence); or
2.
a. are being empirically treated for
MRSA or P. aeruginosa (strong
recommendation, very low quality
of evidence); or
b. were previously infected with MRSA
or P. aeruginosa, especially those
with prior respiratory tract infection
(conditional recommendation, very
low quality of evidence); or
c. were hospitalized and received
parenteral antibiotics, whether during the
hospitalization event or not, in the last
90 days (conditional recommendation,
very low quality of evidence).
Summary of the evidence. Arguments
for trying to determine the etiology of CAP
are that 1) a resistant pathogen may be
identi?ed; 2) therapy may be narrowed; 3)
some pathogens, such as Legionella, have
public health implications; 4) therapy may
be adjusted when patients fail initial
therapy; and 5) the constantly changing
epidemiology of CAP requires ongoing
evaluation.
These arguments stand in contrast to
the lack of high-quality evidence
demonstrating that routine diagnostic
testing improves individual patient
outcomes. Studies that speci?cally evaluated
the use of sputum Gram stain and culture
alone (4每7), or in combination with other
microbiological testing (8每11), also did not
demonstrate better patient outcomes.
The overall poor yield of sputum
evaluation for detecting organisms causing
CAP limits its impact on management and
patient outcomes. Obtaining a valid sputum
specimen can be challenging because of
patient-related characteristics (12每17).
Performance characteristics of testing also
vary by organism, receipt of prior
antibiotics, and setting. For example, in
patients with bacteremic pneumococcal
pneumonia who have not received
antibiotics, microscopic examination and
culture of a good-quality sputum sample
detects pneumococci in 86% of cases (18).
Rationale for the recommendation. In
balancing the lack of evidence supporting
routine sputum culture with the desire for
improved antimicrobial stewardship, the
committee voted to continue the stance of
previous guidelines in recommending
neither for nor against routinely obtaining
sputum Gram stain and culture in all adults
with CAP managed in the hospital setting.
Whether to culture patients or not should be
determined by individual clinicians on the
basis of clinical presentation, local
etiological considerations, and local
antimicrobial stewardship processes.
The committee identi?ed two
situations in which we recommend sputum
e47
AMERICAN THORACIC SOCIETY DOCUMENTS
Table 1. 2007 Infectious Diseases
Society of America/American Thoracic
Society Criteria for De?ning Severe
Community-acquired Pneumonia
Validated de?nition includes either one
major criterion or three or more
minor criteria
Minor criteria
Respiratory rate > 30 breaths/min
PaO2/FIO2 ratio < 250
Multilobar in?ltrates
Confusion/disorientation
Uremia (blood urea nitrogen
level > 20 mg/dl)
Leukopenia* (white blood cell
count , 4,000 cells/ml)
Thrombocytopenia (platelet
count , 100,000/ml)
Hypothermia (core temperature , 368 C)
Hypotension requiring aggressive ?uid
resuscitation
Major criteria
Septic shock with need for
vasopressors
Respiratory failure requiring mechanical
ventilation
*Due to infection alone (i.e., not chemotherapy
induced).
Gram stain and culture: in hospitalized
patients with severe CAP, and when strong
risk factors for MRSA and P. aeruginosa are
identi?ed, unless local etiological data have
already shown these pathogens are very
infrequently identi?ed in patients with CAP.
Patients who have severe CAP requiring
intubation should have lower respiratory tract
samples, such as endotracheal aspirates, sent
for Gram stain and culture promptly after
intubation, particularly as these patients may
be more likely to have pneumonia due to
MRSA or P. aeruginosa, and endotracheal
aspirates have a better yield of microbiological
organisms than sputum culture (19).
We recommend obtaining sputum for
Gram stain and culture in situations when
risk factors for MRSA or P. aeruginosa are
present, both when initial empiric therapy
is expanded to cover these pathogens and
when it is not expanded. In the former case,
negative microbiological test results may be
used to deescalate therapy, and in the latter
case, positive microbiological test results
may be used to adjust therapy. As discussed
later, although there are numerous studies
identifying individual risk factors for MRSA
and P. aeruginosa, many of these
associations are weak and vary across sites.
e48
The most consistently strong risk factor to
consider is prior infection with either
MRSA or P. aeruginosa. In addition,
hospitalization and treatment with
parenteral antibiotics in the last 90 days is
associated with an increased risk of these
pathogens, and so we recommend
sputum culture in this situation. These
recommendations are not based on highgrade evidence but re?ect the committee*s
desire to improve antibiotic use as well as
improve clinicians* understanding of their
local pathogen prevalences and resistance
patterns, which we believe are key to
selecting appropriate empiric antibiotic
therapy.
Research needed in this area. Rapid,
cost-effective, sensitive, and speci?c
diagnostic tests to identify organisms
causing CAP have potential to improve
routine care by supporting the use of
targeted therapy, especially when there
are risk factors for antibiotic-resistant
pathogens. All new diagnostic tests should
be assessed in high-quality research studies
that address the impact of testing strategies
on treatment decisions and patient
outcomes.
Question 2: In Adults with CAP,
Should Blood Cultures Be Obtained at
the Time of Diagnosis?
Recommendation. We recommend not
obtaining blood cultures in adults with CAP
managed in the outpatient setting (strong
recommendation, very low quality of
evidence).
We suggest not routinely obtaining blood
cultures in adults with CAP managed in the
hospital setting (conditional recommendation,
very low quality of evidence).
We recommend obtaining
pretreatment blood cultures in adults with
CAP managed in the hospital setting who:
1. are classi?ed as severe CAP (see Table 1)
(strong recommendation, very low
quality of evidence); or
2.
a. are being empirically treated for
MRSA or P. aeruginosa (strong
recommendation, very low quality of
evidence); or
b. were previously infected with MRSA
or P. aeruginosa, especially those
with prior respiratory tract infection
(conditional recommendation, very
low quality of evidence); or
c. were hospitalized and received
parenteral antibiotics, whether during
the hospitalization event or not,
in the last 90 days (conditional
recommendation, very low quality of
evidence).
Summary of the evidence. There are no
high-quality studies that speci?cally
compared patient outcomes with and
without blood culture testing. One large
observational study found lower mortality
for hospitalized patients associated with
obtaining blood cultures at the time of
admission (20). Three subsequent (smaller)
observational studies found similar
associations between in-hospital mortality
and having blood cultures within 24 hours
of admission, but the results were not
statistically signi?cant (8, 21, 22).
The yield of blood cultures in most
series of adults with nonsevere CAP is low,
ranging from 2% (outpatients) to 9%
(inpatients) (14, 21, 23, 24); furthermore,
blood cultures rarely result in an
appropriate change in empiric therapy (25),
and blood specimens that include skin
contaminants can generate false-positive
test results. Growth of organisms such as
coagulase-negative staphylococci, which are
not recognized as CAP pathogens (26), may
lead to inappropriate antimicrobial use that
increases the risk for adverse drug effects.
A study of adults hospitalized with CAP
found blood cultures were associated with
a signi?cant increase in length of stay and
duration of antibiotic therapy (27). Given the
observational nature of these studies, it is
unknown whether the associations found with
blood cultures and patient outcomes were
causal or due to unmeasured confounding
factors, including severity of illness.
Rationale for the recommendation.
Although additional diagnostic information
could improve the quality of treatment
decisions, support for routine collection of
blood cultures is reduced by the low quality of
studies demonstrating clinical bene?t. Routinely
obtaining blood cultures may generate falsepositive results that lead to unnecessary
antibiotic use and increased length of stay.
In severe CAP, delay in covering lesscommon pathogens can have serious
consequences. Therefore, the potential bene?t
of blood cultures is much larger when results
can be returned within 24 to 48 hours.
The rationale for the recommendation
for blood cultures in the setting of risk
factors for MRSA and P. aeruginosa is the
same as for sputum culture.
American Journal of Respiratory and Critical Care Medicine Volume 200 Number 7 | October 1 2019
AMERICAN THORACIC SOCIETY DOCUMENTS
Table 2. Differences between the 2019 and 2007 American Thoracic Society/Infectious Diseases Society of America
Community-acquired Pneumonia Guidelines
Recommendation
2007 ATS/IDSA Guideline
2019 ATS/IDSA Guideline
Sputum culture
Primarily recommended in patients with
severe disease
Now recommended in patients with severe
disease as well as in all inpatients
empirically treated for MRSA or
Pseudomonas aeruginosa
Blood culture
Primarily recommended in patients with
severe disease
Now recommended in patients with severe
disease as well as in all inpatients
empirically treated for MRSA or P.
aeruginosa
Macrolide monotherapy
Strong recommendation for outpatients
Conditional recommendation for outpatients
based on resistance levels
Use of procalcitonin
Not covered
Not recommended to determine need for
initial antibacterial therapy
Use of corticosteroids
Not covered
Recommended not to use. May be considered
in patients with refractory septic shock
Use of healthcare-associated pneumonia
category
Accepted as introduced in the 2005
ATS/IDSA hospital-acquired and
ventilator-associated pneumonia
guidelines
Recommend abandoning this categorization.
Emphasis on local epidemiology and
validated risk factors to determine need for
MRSA or P. aeruginosa coverage.
Increased emphasis on deescalation of
treatment if cultures are negative
Standard empiric therapy for severe CAP
b-Lactam/macrolide and
b-lactam/?uoroquinolone combinations
given equal weighting
Both accepted but stronger evidence in favor
of b-lactam/macrolide combination
Routine use of follow-up chest imaging
Not addressed
Recommended not to obtain. Patients may be
eligible for lung cancer screening, which
should be performed as clinically indicated
Definition of abbreviations: ATS = American Thoracic Society; CAP = community-acquired pneumonia; IDSA = Infectious Diseases Society of America;
MRSA = methicillin-resistant Staphylococcus aureus.
Question 3: In Adults with CAP,
Should Legionella and Pneumococcal
Urinary Antigen Testing Be Performed
at the Time of Diagnosis?
Recommendation. We suggest not
routinely testing urine for pneumococcal
antigen in adults with CAP (conditional
recommendation, low quality of
evidence), except in adults with severe
CAP (conditional recommendation, low
quality of evidence).
We suggest not routinely testing urine
for Legionella antigen in adults with CAP
(conditional recommendation, low quality
of evidence), except
1. in cases where indicated by
epidemiological factors, such as
association with a Legionella outbreak
or recent travel (conditional
recommendation, low quality of
evidence); or
American Thoracic Society Documents
2. in adults with severe CAP (see Table 1)
(conditional recommendation, low
quality of evidence).
We suggest testing for Legionella
urinary antigen and collecting lower
respiratory tract secretions for Legionella
culture on selective media or Legionella
nucleic acid ampli?cation testing in
adults with severe CAP (conditional
recommendation, low quality of evidence).
Summary of the evidence. Falguera and
colleagues (28) randomized 177 patients to
pathogen-directed treatment (targeted
treatment) on the basis of results of urinary
antigen testing for S. pneumoniae and
Legionella versus empirical guidelinedirected treatment. Of the 88 patients in the
targeted treatment arm, 25% had a positive
urinary antigen test and received pathogendirected therapy. There were no statistical
differences in death, clinical relapse, ICU
admission, length of hospitalization, or
length of antibiotic treatment (28). A
second trial of 262 patients included
a broader range of microbiological testing
(sputum and blood cultures) and only
Legionella urinary antigen testing, but
patients receiving pathogen-directed
therapy had similar clinical outcomes to
patients receiving empirical, guidelinedirected therapy, including mortality, rates
of clinical failure, and length of
hospitalization (10).
One observational study evaluated cost
and antibiotic selection in patients during
two time periods, with and without
pneumococcal urinary antigen testing, but
found no differences during the two
time periods (29). In contrast, other
observational studies that have evaluated
the impact of prior CAP guideline
concordance (including initial diagnostic
testing with urinary antigen tests and
blood cultures, along with site of care
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